Exploring the experience of reablement: A systematic review and qualitative evidence synthesis of older people's and carers' views

Abstract Concerns from the worldwide ageing population and evidence of poor‐quality aged care services have highlighted the need to develop innovative models of aged care which are acceptable to older people, economically sustainable and are safe. Reablement is a relatively new model for aged care that aims to support older people's desires to age independently in their usual place of residence and decrease dependency on aged care services. This qualitative evidence synthesis aimed to explore the experiences of older people and their carers (formal and informal) towards a reablement model of community aged care to ensure services are considerate of older people's needs. A systematic search was conducted across six electronic databases (Medline, Scopus, CINAHL, PsycINFO, Cochrane Library and Google Scholar) from 1990 to September 2021. Qualitative research exploring older people and their carers' experiences and perceptions of the reablement model used in community aged care services were identified. Nineteen articles were included in the synthesis following the screening of 668 abstracts and 56 full texts. Included articles were subject to quality assessment, and the data were synthesised using thematic synthesis. Three analytical themes were generated from the thematic synthesis; (i) reablement is a shift in approach to aged care, (ii) difficulties in developing tangible and meaningful reablement goals, (iii) reablement improves health and well‐being. Reablement is generally well‐received by older people and their informal carers. However, poor engagement from older people did occur when they had a poor understanding of their role in reablement and when they had not been fully consulted regarding their reablement goals. Current and future reablement services for older people should focus on ensuring an awareness of the processes and principles of reablement and collaboration between practitioner, the older person and their carer when developing goals to increase engagement.

Representing a shift from traditional aged care services which have focused on delivering long-term dependency-based services typical reablement services offer time limited (generally described as up to 12 weeks) interventions including exercise, behaviour modification and activities of daily living retraining (Lewis et al., 2021;Metzelthin et al., 2017Metzelthin et al., , 2020. Four systematic reviews have investigated the clinical effectiveness of reablement and whether it increases older people's independence and decreases ongoing needs for aged care services. The four reviews identified a small number of primarily poor-quality articles of mixed or contradictory outcomes; as such the effectiveness of reablement is yet to be fully evaluated (Cochrane et al., 2016;Legg et al., 2016;Sims-Gould et al., 2017;Tessier et al., 2016).
The experiences of older people who have been involved with reablement are an important consideration so that services can be appropriately tailored to meet their needs. The aim of this systematic review of qualitative literature particularly focuses on the experiences of older people and their carers (formal and informal). The review will explore the experiences, opinions and attitudes towards the reablement model of community aged care. Expanding our understanding is especially relevant at this time when countries are increasingly adopting reablement into their aged care services.

| ME THODS
A range of qualitative evidence synthesis (QES) methods are available, and selection is based on multiple factors, including the research question, epistemological assumptions, audience and purpose (Noyes et al., 2018). Based on the objective of our study to understand and evaluate multiple contextual insights from users' experience of the reablement model, we utilised the thematic synthesis method developed by Thomas and Harden (2008). The thematic synthesis approach to QES allows for inductive coding and flexible exploration of data from multiple contexts to interpret and construct meaning from experiences of the phenomena (Barnett-Page & Thomas, 2009). Our process for identification and selection of articles followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines .

What is known about the topic
• Reablement is associated with healthy ageing and aimed at decreasing older people's dependence on long-term aged care.
• Despite the growing popularity of reablement in aged care services, the clinical effectiveness has not been fully evaluated.

What this paper adds
• Older people value the principles of reablement.
• Older people's poor engagement in reablement services can be attributed to a poor understanding of their role in reablement and a lack of collaboration in reablement goals.
• Further research aimed at increasing the motivation and engagement of older people during reablement is required.

| Inclusion and exclusion criteria
We established the inclusion and exclusion criteria prior to screening (see Appendix S1).

| Inclusion criteria
We included qualitative studies that were either stand-alone or included as part of a larger quantitative study or an evaluation study with an identifiable qualitative component. Mixed-methods studies were included if they separately reported qualitative data collection and analysis. Studies reporting views from a range of experiences and perspectives were included if data between older people and their carers were distinctly identifiable from other, for example, professionals, data. All qualitative design, methodology and analysis techniques were included. Grey literature was also included.

| Phenomena of interest
Experiences and perceptions of the reablement model in aged care.

| Contexts
The thematic synthesis included studies undertaken where the reablement model has been used to deliver care for older people living in their private residence in their community. We chose this context to maintain some homogeneity of the setting and experience.

| Participants
Included studies explored the experiences of the delivery of the reablement model of care from the perspective of the older person receiving care and their carers (formal or informal). For this review 'older people' were defined as aged 65 years and older.

| Exclusion criteria
Reablement is an approach to aged care that has been introduced over the past three decades, so we limited our search to studies published from 1990 (Clotworthy et al., 2021). Papers were excluded if they were (i) not published in English, (ii) literature reviews, (iii) based solely on quantitative data and (iv) based solely on the perspectives of healthcare professionals. Studies with participants who permanently resided in long-term aged care facilities and who were provided care 24 h a day, 7 days a week, were also excluded in line with the aim of the study which was centred on older adults living in the private home setting in their local community.

| Study selection process
Studies were exported from each database into EndNoteX9 (EndNote, 2018) and then transferred to the Covidence software package (Covidence, 2019), which was used to manage the screening and selection process. Abstracts were screened by both reviewers using a priori inclusion and exclusion criteria (see Appendix S1).
Conflicts were resolved through discussion between both reviewers.
Following abstract screening, full texts were reviewed in Covidence, with conflicts resolved through discussion. The reference lists of included studies were also screened. Full screening details are presented in the PRISMA diagram ( Figure 1).

| Appraisal of study quality
All studies were appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research (JBI QARI) (Lockwood et al., 2015). The JBI QARI is a 10-item instrument used for the quality assessment of qualitative research. Items are assessed as 'yes', 'no', 'unclear' or 'not applicable. The checklist assesses for congruence between philosophical perspectives, methodology selection, data analysis methods, interpretation of results and conclusions and that participant voices are adequately represented.

| Data extraction, analysis and synthesis
Data extraction and synthesis of the included papers followed the 'thematic synthesis' method, a three-step process developed and described by Thomas and Harden (2008). All included papers were imported into NVIVO 12 Pro (NVivo, 2018). Results sections were then inductively coded line-by-line to produce 'free codes' which summarise and capture the meaning of the published text (Thomas & Harden, 2008). Free codes with similar meaning were then organised together into groups which were then labelled with new codes that described the shared meaning of the free codes. This process helped with translating similar concepts found across the included papers into more manageable data used to develop analytical themes. Until this point, the developed themes had been firmly rooted in the primary studies and not considered in relation to the review objective.
Therefore, in the third stage, the descriptive themes were analysed, and their relevance considered against the review questions to generate analytical themes. Throughout all three stages of the process, reference to primary data source was undertaken to ensure that generated ideas were accurately representing the data. To test for internal validity of the generated analytical themes, coding from a random sample of included studies using the final framework was completed by Jodi Oakman (an experienced qualitative researcher).

| Reflexive note
Analysis of the data was conducted within the epistemological stance of critical realism, which assumes that our understanding of reality is mediated by our beliefs and perceptions (Barnett-Page & Thomas, 2009). Critical realism includes elements of both realist and constructionist paradigms, acknowledging individuals' different perspectives in their understanding of reality (Braun & Clarke, 2013;Chouliaraki, 2002;Kuhn & Westwell, 2012). We used this approach as critical realists seek to make recommendations for policy and practice, which are based on an explanation of individuals' tendencies and causal mechanisms (Fletcher, 2017). The main analysis was conducted by one researcher Lachlan Mulquiny, who has a background in podiatry. The initial themes and the analysis were discussed and reviewed by the co-author Jodi Oakman who is an experienced practitioner and researcher with a background in physiotherapy, ergonomics and human factors.

| Search strategy and study selection
Our initial database search identified 10 articles that met the inclusion criteria. From the September 2021 database search, a further seven articles were identified as meeting the inclusion criteria. Two articles were added after being identified through reference checking the included articles. A total of 19 articles were included for appraisal and synthesis. The PRISMA diagram is shown in Figure 1. from the perspective of reablement service professionals; however, the data from these individuals was clearly distinguishable and was excluded from the thematic synthesis. Two papers reported on data collected during the same study (Glendinning et al., 2010;Wilde & Glendinning, 2012). Both papers have been included in the thematic synthesis given their varied reporting styles, including quotations and exploration of concepts, which we believe improved the richness of the dataset used for synthesis. Further characteristics of the included studies are provided in Table 1. Full text arƟcles excluded, n = 39 14 Wrong intervenƟon 7 Wrong study design 3 Conference paper 2 Wrong outcomes 13 Not service user and/or carer view ArƟcle added via reference in another paper (n = 2)

| Thematic synthesis
Three analytical themes were generated from the synthesis of findings from the included studies: reablement is a shift in approach to aged care; difficulties in developing tangible and meaningful reablement goals; reablement improves health and well-being.

| Theme 1-Reablement is a shift in approach to aged care
The aims and processes of reablement, with a focus on restoring lost capacities to improve older people's ability to perform activities for daily living, were often misunderstood by older people and their carers who were expecting services that would compensate for their losses in function.  Carers of people receiving a reablement service n = 10

Misunderstanding of reablement
Semi-structured interview Thematic analysis through a priori framework and emergent themes from interviews Exploration of service users' experiences of reablement, the outcomes for the users themselves, their perceptions of the ways reablement had affected any informal carers; and any outstanding unmet needs Abbreviation: QES, qualitative evidence synthesis.

TA B L E 1 (Continued)
the potential to negatively impact reablement outcomes (

| Theme 2-Developing reablement goals
Developing goals for the older person are a fundamental step in the reablement process. A key finding across the included stud-  and goals were imposed that did not align with their lifestyle preferences leading to decreased engagement during the reablement period. (Bødker et al., 2019;Chung, 2019;Golenko et al., 2021;Moe & Brinchmann, 2016;Rahja et al., 2020). Further, goal setting was often seen as a 'new skill' and a difficult task which was not appropriate for them given their age: 'I think achieving my goals is history. I'm 73 years of age ' (Golenko et al., 2021).

Caregivers perspectives for goal setting
Carers were often excluded from the reablement process despite their wish to be involved (Glendinning et al., 2008;Jakobsen et al., 2019;Wilde & Glendinning, 2012). Carers voiced concerns of being overlooked as a resource to provide alternative perspectives and insights into the current health status of the older person, which could be overlooked Jakobsen et al., 2019). Tensions between older people and their carers (most often family members) arose when views and perspectives diverged in the development of attainable reablement goals . Some carers felt that due to their responsibilities in the care-giving relationship, including navigating various aspects of care and assistance with everyday tasks, they could provide helpful input into the development of strategies to assist with achieving reablement goals Moe & Brinchmann, 2016).
The following quote from a family member illustrates these concerns: 'We discovered that one of the goals of our family member's reablement was to go down the basement stairs to wash clothes. As family, we disagreed with this goal because in our opinion, the basement stairs are steep and dangerous for her. We wanted her to have a washing machine in the kitchen. I think it is necessary and important that the reablement service collaborate with the relatives and request their opinion of the goals' .

Individual independence
Older people reported their achievements during the reablement period were appropriate for 'in the home' but the programme did not address their social isolation (

| Theme 3-A sense of improved health and well-being
The following sub-themes explore the improvements in health and well-being from the perspectives of older people and their carers.

Older persons improved health and well-being
Many older people had a positive opinion of the underlying principles of reablement, particularly its focus on enabling them to maintain independence in their usual residence and promo- '… it's just the fact that another human being comes to see you that makes you feel better and gives you the bit of confidence' (Beresford et al., 2019).
However, it was common that at the end of the reablement period, some older people did not continue with activities to maintain the gains made during the programme. One reason reported by older people for abandoning the activities and exercises undertaken during reablement was a lack of support or encouragement once the official service had ended (Bødker et al., 2019;Hjelle, Tuntland, et al., 2017;Jokstad et al., 2020). For some older people, the ending of reablement was associated with anxiety as they were concerned that there would be negative impacts on their health and function without a connection to their reablement clinicians (Bødker et al., 2019;McLeod & Mair, 2009;Whitehead et al., 2018;Wilde & Glendinning, 2012).

Improved carer well-being
Carers reported improved confidence through observing reablement clinicians and developing new and more structured caring skills (Jeon et al., 2019;Wilde & Glendinning, 2012). These newly acquired skills helped them support older people's performance and assist them with sustaining improvements made during the reablement period (Glendinning et al., 2010;Wilde & Glendinning, 2012). The impact of improving their family member's independence resulted in benefits for carers who now had additional free time for their own everyday life activities (Glendinning et al., 2010;Jeon et al., 2019;Wilde & Glendinning, 2012).

| DISCUSS ION
This review is the first QES to explore the experiences of older people and their informal care networks receiving aged care in the community informed by the reablement model. Traditional aged care services have typically been focussed on delivery of domestic services where older people are passive recipients. In contrast, delivery of reablement is aimed at increasing self-sufficiency and independence in the home through active engagement from the older person (Aspinal et al., 2016;Jacobi et al., 2020). Our synthesis found that confusion and misunderstanding of the aims and process of reablement negatively impacted older persons engagement and participation during their reablement process (Beresford et al., 2019;Bødker et al., 2019;Ghatorae, 2013;Hjelle, Tuntland, et al., 2017;Jokstad et al., 2020;McLeod & Mair, 2009;Rahja et al., 2020;Wilde & Glendinning, 2012).
Therefore, as suggested by Stausholm et al. (2021), it is important for clinicians to effectively communicate the aim and content of reablement in an understandable way to maximise engagement and improve collaboration during the goal development phase.
Goals were often viewed as an important motivator to improve independence and were a means of 'looking forward to be the person they were before' (Hjelle, Tuntland, et al., 2017).  reported that tensions arose between older people and those in their informal care networks regarding the appropriateness and prospect of achieving goals identified by the older person.
Moreover, some family members felt overlooked in the goal setting stage and reported that they would appreciate an invitation to provide further information and perspective of their family members current situation to help contribute to possible solutions . This experience is not unique to the reablement model of care, and Plant et al. (2016) have previously suggested that successful goal setting in these circumstances includes building consensus between the service participant and their family, to ensure that goals are holistic and not unrealistic. In practice, this involves open dialogue where the older person, their carers and clinicians can share knowledge and different perspectives regarding the appropriateness and achievability of goals and arrive at a common understanding (Legare et al., 2011;Siegert & Taylor, 2004).
Both older people and their carers identified the setting of goals was an important indicator for success in reablement, but only when the older person felt that consultation was adequate and goals were congruent with their meaning of independence (Beresford et al., 2019;Chung, 2019;Golenko et al., 2021;Hjelle, Tuntland, et al., 2017;Jokstad et al., 2020;McLeod & Mair, 2009;Wilde & Glendinning, 2012). Our synthesis found the definition of independence was frustrating for older people when it was narrowly defined as completion of activities of daily living and did not include their social needs (Beresford et al., 2019;Bødker et al., 2019;Östlund et al., 2019;Wilde & Glendinning, 2012).
Some older people reported that their goals to be more socially active were not considered to guide their reablement, instead, the goals of their reablement tended to reflect the priorities of governments and local aged care services to deliver short-term interventions aimed at decreasing user dependency on ongoing supportive services (Beresford et al., 2019;Bødker et al., 2019;Östlund et al., 2019;Wilde & Glendinning, 2012). This perception has also been reported by reablement professionals who described a tension between local government priorities to reduce demand on social services and disinterest from older people to do some tasks (e.g. home cleaning, bathing) for themselves (Stausholm et al., 2021).
The issues of social isolation and loneliness in older people are well documented (Gardiner et al., 2018;Luanaigh & Lawlor, 2008).
Social isolation and loneliness in older age have been associated with depression, decreased cognitive function, increased cardiovascular disease and mortality (Courtin & Knapp, 2015).  (2020), we also encourage reablement services for older people to place greater attention on increasing social connectivity.
The ending of reablement was described by both older people and their carers as abrupt, and that sustaining the functional gains made during the period was difficult to achieve (Beresford et al., 2019;Jokstad et al., 2020;Östlund et al., 2019).  reported concern from carers of a missing link that would help sustain functional gains and suggested a smoother transition was needed at the end of the reablement programme. In addition to insufficient follow-up, when older people were referred to services following the reablement programme, it often involved a return to dependent models of care with limited scope to sustain functional gains made during their reablement period (Bødker et al., 2019;Whitehead et al., 2018). These findings suggest that older people and their carers considered reablement an ongoing process that cannot be limited to short-term programmes (Beresford et al., 2019;Bødker et al., 2019;Östlund et al., 2019;Whitehead et al., 2018;Wilde & Glendinning, 2012). Carers believed that care services delivered after reablement were orientated towards older people being passive recipients of dependent care and would hinder sustaining the gains made during reablement, leading to another decline and return to pre-reablement levels of function.
Positive experiences of receiving reablement interventions included the emergence of a more optimistic outlook and empowerment that supported progress towards the older person's independence, allowing the older person to maintain independence within their usual place of residence (Beresford et al., 2019;Magne & Vik, 2020).
Positive experiences are consistent with the intent of the reable-

| Strengths and limitations
We conducted a comprehensive literature search of six electronic databases and screened reference lists of included studies. We took the additional step to include grey literature to maximise eligible studies. Both reviewers were involved in the screening, data extraction and quality appraisal stages of the review. Some limitations of this review were noted, such as limiting the search strategy to English which may have resulted in the omission of some relevant papers. Second, inherent with qualitative research, we acknowledge that thematic analysis of the data may be interpreted differently by reviewers with different backgrounds and experiences.

| CON CLUS ION
This review of qualitative studies explored the experiences of older people and their carers who had participated in reablement informed community aged care. Older people and their carers value the underlying principles of reablement to support independence in their usual place of residence. However, some older people found that the short time periods for reablement services were insufficient for their level of disability and considered a need for ongoing interventions.
Older people also felt their reablement goals tended to ignore their need for social connectedness.

ACK N OWLED G EM ENTS
Open access publishing facilitated by La Trobe University, as part of the Wiley -La Trobe University agreement via the Council of Australian University Librarians.

CO N FLI C T O F I NTE R E S T
There is no conflict of interest to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.